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A torn ACL means that the athlete will not return for the rest of the season. But, what happens next. Initially, there needs to be a discussion between the surgeon and the patient. Surgery for an ACL is not always a need. For those that are more active, such as athletes, surgery to repair the torn ACL is highly recommended. Nonsurgical treatment may be appropriate for patients who are less active, those that do not participate in activities that require running, jumping, or pivoting, and who would be interested in physical therapy to return range of motion and strength to match the uninjured leg.

The International Knee Documentation Committee, which is an association of American and European orthopedic surgeons, developed a questionnaire to standardize the activity level assessment of patients before and after surgery to help guide surgeons and patients to decide whether surgery would be helpful. The activity levels were as follows, Level I: jumping, pivoting, and hard cutting, Level II: heavy manual work or side-to-side sport, Level III: light manual work and noncutting sports like running and bicycling, and Level IV: sedentary lifestyle without sports

Young athletes should almost always have surgery to repair an ACL since there is potential for these athletes to have chronic knee instability for the reminder of their life. Those patients that fall between level III and level IV may be candidates for a nonsurgical approach. The main goal of nonoperative treatment is to return strength and range of motion to the injured knee with physical therapy and exercise rehabilitation. Although a patient may be comfortable with nonsurgical treatment there may still be an option to discuss associated cartilage damage, or remove bony changes within the knee. This requires arthroscopic surgery. A patient may recover from this type of surgery within a several weeks.The anterior cruciate ligament can be reconstructed by an orthopedic surgeon using arthroscopic surgery. There are a variety of techniques, depending on the type of tear and what other injuries may be associated. The decision as to what surgical option is appropriate is individualized and tailored to a patient’s specific situation. Because of its blood supply and other technical factors, the torn ACL ends are not usually sewn together and instead, a graft is used to replace the ACL. Often an autograft, tissue taken from the patient’s own body, is a piece of hamstring or patellar tendon that is used to reconstruct the ACL.

It may take six to nine months to return to full activity after surgery to reconstruct an ACL injury. The first few weeks are devoted to gradually increasing range of motion. The graft needs time to heal. Regaining full extension and flexing to approximately 90 degrees is important to successfully progress through rehabilitation. Range of motion should ideally be regained but 6 weeks. At this point stationary bicycle can be used to maintain range of motion. Strengthening exercises begin at this time as well.The next four to six months is used to restore knee to normal function, how it was before the injury. Strength, agility, and proprioception, the ability to recognize the position of the knee in space, are increased under the guidance of a physical therapist and regular visits with the orthopedic surgeon.

How long does it take to recover from a torn ACL? As mentioned previously, rehabilitation and return to normal function after surgery can take six to nine months. There should be a happy balance with the exercises, overworking vs. underworking. Being too aggressive can damage the surgical repair and cause the ligament to fail again. Too little work lengthens the time to return to normal activities.

What is the prognosis of a torn ACL? More than 80% of people who have surgery to repair their ACL have good return of function and lifestyle. For patients who do not have surgery to repair a torn ACL, 50% have a fair outcome with no knee instability.

Can ACL tears be prevented? ACL injuries are not limited to basketball players, as we’ve seen with Olympic skier Lindsey Vonn. ACL injuries can occur in an active person. To decrease the chances of injury, maintaining strength and flexibility is important. Plyometric exercises to help build power, strength, speed, and balance (proprioception) can teach the body how to jump and land properly to minimize the risk of injury. It is important to avoid landing on a fully extended and locked leg.

Ultimately, the main treatment goal is to return the patient to his or her preinjury level of function, with surgery or not.

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Winter Olympics has officially begun. It will be without Ski champion Lindsey Vonn. She underwent a successful knee surgery, following an injury that forced her to pull out of the Olympics just weeks before the US team was set to leave for Sochi.

Vonn had ACL reconstruction in January 2014 by the world-renowned sports medicine Dr. James Andrews. Our very own Dr. Brown had the pleasure of working with him during her training. Vonn hopes to be back competing in February of 2015, and Dr. Andrews is confident that she will.

It all began with an injury she sustained a year ago. Vonn, who has 59 World Cup race victories to her credit and who is the reigning Olympic downhill champion, badly injured her knee while competing in a super-G at the World Championships in February 2013. She tore her anterior cruciate ligament (ACL), medial collateral ligament (MCL) and fractured her lateral tibial plateau. Dr. William Sterett of Vail-Summit Orthopaedics performed ACL reconstructive knee surgery in Vail, Colo. After an ACL reconstruction, female athletes are particularly vulnerable to a second ACL injury, a recent study showed.

After reconstructive surgery, and a lengthy layoff, Vonn returned to World Cup competition at Lake Louise, Canada in early December 2013. She unfortunately injured the same knee while training in Copper Mountain, Colorado in November 2013. She suffered a partial tear of the anterior cruciate ligament of right knee following the crash.

She continued to compete. At Lake Louise, Vonn was 40th in the first downhill, 11th in a second downhill and fifth in a super-G. She then competed in a downhill at Val d’Isere in the French Alps just before Christmas 2013, where she skied off course during world cup downhill run in Val d’Isere clutching her knee. She was diagnosed with a medial collateral ligament sprain.

In early January 2014 Vonn announced she would not compete in the Sochi Winter Games. In a statement, she said: “I did everything I possibly could to somehow get strong enough to overcome having no ACL but the reality has sunk in that my knee is just too unstable to compete at this level.

The anterior cruciate ligament (ACL) is one of the main stabilizing ligaments in the knee, and it is the most commonly torn ligament in the knee. It prevents the thighbone (femur) from moving forward on the shinbone (tibia). It may be torn by pivoting and twisting the knee, or by hyperextension. Landing awkwardly from a jump may also result in a torn ACL. Symptoms include hearing or feeling a pop in the knee, swelling in the knee, pain, and a feeling of instability, especially with side to side movement. The knee may “give way” or “buckle” with weight-bearing. An athlete in a sport which requires pivoting, cutting, or jumping requires surgical reconstruction to prevent recurrent episodes of instability and further knee damage such as meniscus tears and cartilage damage. The surgery involves reconstructing a new ACL from either the athlete’s own tissue or donor tissue from a cadaver. The rehabilitation process after surgery takes several months, and return to play depends on the type of surgery and the sport, however on average the recovery time is 7 to 10 months.

Women are more likely to tear their ACL than men for a number of reasons. One is the anatomical difference in the knee-joint, the space where the ACL sits is narrower in women, and so the ligament has less room when the knee is hyperextended or twisted and therefore more prone to injury. Another reason is the alignment of the female knee as compared to the male knee. Women in general have wider hips and therefore place increased stress on the ACL when the knee is twisted.

Additionally there are hormonal differences in women, which may make the ligaments looser and more prone to tearing. Lastly, an important factor in ACL injury is conditioning and muscle strength of the muscles surrounding the knee. There are a number of conditioning programs specifically designed to reduce a female athlete’s risk of ACL tear.

Provided by Primus Sports Medicine Staff

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After a long workout, a massage has can have significant effects on the body and its recovery. Foam rollers can offer the same benefits as massage but for a much smaller cost. A foam roller can stretch the muscles and tendons, and it can also break up soft tissue adhesions, or scar tissue. Using your body weight to press against the foam roller allows you to perform a self-massage, myofasical release, and increase blood flow and circulation to the soft tissues

What is myofascial release? Myofascial release is a bodywork technique in which a practitioner uses gentle, sustained pressure on the soft tissues while applying traction to the fascia. This technique results in softening and lengthening (release) of the fascia and breaking down scar tissue or adhesions between skin, muscles and bones

What is fascia? The superficial fascia is a soft connective tissue located just below the skin. It wraps and connects the muscles, bones, nerves and blood vessels of the body. Together, muscle and fascia make up what is called the myofascial system.

Myofascial release can relieve several muscle and joint pains, such as, IT band syndrome (see previous blogs), medial tibial stress syndrome (AKA “shin splints”), also improving flexibility and range of motion. As mentioned previously, foam rollers are inexpensive and with a bit of experimentation you can target just about any muscle group.

How to use the foam roller?

Using a foam roller is pretty easy, however, it may take some practice, and some strange body positions, in order to target your problem areas. First, you need an open floor space. Second, position your body on top of the foam roller, paying attention what area bothers you, for example, for IT band issues you will lay on top of the foam roller on either your left or right side. Your body weight creates the pressure, so try to relax. You control the pressure by applying more or less body weight on the foam roller and using your hands and feet to offset your weight as needed. It’s helpful to try a variety of positions and see what works best for you.

Tips for Using a Foam Roller

Always check with your doctor before using a foam roller for myofascial release.

Do not use a foam roller without your physician’s approval if you have any heart or vascular illness or a chronic condition.

Perform foam roller sessions when your muscles are warm or after a workout.

Position the roller under the soft tissue area you want to release or loosen.

Gently roll your body weight back and forth across the roller while targeting the affected muscle.

Move slowly and work from the center of the body out toward your extremities.

If you find a particularly painful area (trigger point), hold that position until the area softens.

Focus on areas that are tight or have reduced range of motion.

Roll over each area a few times until you feel it relax. Expect some discomfort. It may feel very tender or bruised at first.

Stay on soft tissue and avoid rolling directly over bone or joints.

Keep your first few foam roller sessions short. About 15 minutes is all you need.

Rest a day between sessions when you start.

After a few weeks you can increase your session time and frequency if you choose.

Drink plenty of water after a session, just as you would after a sports massage.

Provided by Primus Sports Medicine Staff

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Cryokinetics is a therapeutic process that includes the application of external cold therapy to an area of the body that has recently been injured. Various cooling modalities are used to apply cold to the injured area, e.g. ice packs, ice towels, ice massage, frozen gel packs, ethyl chloride and other vapocoolants, chemical reaction devices and inflatable splints using refrigerant gas. Cold therapy is followed by full passive range of motion and progressive active exercises. This technique has proven to be very successful, especially with ligament sprains of the ankle.

The purpose of cryokinetics is to initiation early, pain-free range of motion and exercise following an injury. The anaesthesia, or affect of numbness, that arises from the application of ice does not remove pain-sensing mechanisms; it simply removes the current pain from the damage of the tissues. Ultimately, if active exercise is too vigorous pain can still occur.

Ice Bath

Application. Cold should be applied for a maximum of 20 minutes, which is enough time to produce the numbed response without causing damage to superficial tissues. Once the patient feels numb, passive range of motion can be initiated. If the numbing affect begins to go away, the same cold process used before can be used again for about 5 minutes, or until numbing is felt again. After successful, pain-free, range of motion has been initiated, active exercise can be performed by the patient. Active exercises can included, but are not limited to, resisted range of motion, gait training, and calf raises. Each exercise can be increased in intensity as long as patient remains pain-free. The key to the success of cryokinetics appears to be progressing as quickly as possible from one exercise to the other. I personally recommend an ice bath or ice slush for acute ankle sprains. This introduces the cold therapy but also allows the athlete to begin range or motion, and some exercise, while numbing starts.

Benefits. As mentioned previously, cryokinetics allows early and pain-free range of motion and exercise. Exercise helps increase blood flow to the injured area, very important in healing, once the initial acute phase has passed and any bleeding has stopped.

Passive ROM

Cryokinetic exercise re-establishes neuromuscular function, and atrophy or wasting of the muscles has not had time to set in. Swelling is reduced dramatically through the combination of cooling and exercise. Be advised, motor performance is affected by temperature with a critical temperature being around 18 degrees C, above and beneath which muscle performance decreases. There is also a critical temperature for the application of cold with inflammation and edema increasing at temperatures below 15 degrees C. Precautions should be taken because prolonged application at very low temperatures could have deleterious effects.

Applying cryokinetics immediately following an acute, but minor, injury can help athletes return to activity very quickly. Most clinical studies report that the use of cryotherapy, such as cryokinetics, has a positive effect on pain reduction and on the recovery of various injuries. Those with minor ankle sprains have the potential return to sport within days of the injury. Cryokinetics can be the difference of having your star player hit the game winning shot or sit on the bench. It is worth a try.

Provided by Primus Sports Medicine Staff

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The Seahawks All-Pro cornerback Richard Sherman left in the fourth quarter of the Super Bowl with an apparent ankle injury. He appeared to be writhing in pain on the ground after assisting on a tackle of Demaryius Thomas who had made a reception. It was the second time in the game Sherman had to leave the field because of an injury to his ankle. He was placed in a walker boot, and given crutches. It appears he sustained a high ankle sprain.

What is a High Ankle Sprain?

A high ankle sprain is injury to the higher ankle ligaments, which are located above the ankle joint (closer to the knee with respect to the ankle).

These high ankle ligaments connect the tibia (shin bone) to the fibula (outside leg bone). The injury involves the syndesmosis between the lower tibia and fibula just above the ankle joint.The syndesmosis is a fibrous joint where the two leg bones are connected together by ligaments or connective tissue and usually have very little mobility. High ankle sprains are much less common but are more disabling than a traditional lower ankle sprain. They must be diagnosed at an early stage and appropriate treatment initiated. Treatment of high ankle sprains differs from a lower ankle sprain.

What Causes a High Ankle Sprain?

High ankle sprains most commonly occur when the foot is planted on the ground and then an excessive outwards twisting of the foot occurs.

High ankle ligaments can also sprain when the ankle is loaded severely and pushed into excessive dorsiflexion. This often occurs in football tackles as with Richard Sherman.

What are the Symptoms of a High Ankle Sprain?

High ankle sprains occur following a traumatic ankle injury. Patients often report:

Pain felt above the ankle that increases with outward rotation of the foot.

Pain with walking and often significant bruising and swelling across the higher ankle rather than around the malleolus.

The severity of symptoms will depend on the grade of ankle sprain: mild, moderate, and severe. Patients with a high ankle sprain without fracture may be able to bear weight, but will have pain over the junction between the tibia and fibula just above the level of the ankle. This is higher than the more traditional sprains.

How is a High Ankle Sprain Diagnosed?

If high ankle sprain is suspected an X-ray, CT scan or MRI maybe ordered to confirm the diagnosis, after performing a physical examination.

What is the Usual Treatment for a High Ankle Sprain?

The vast majority of high ankle sprains are treated conservatively (non-operatively) with splinting of the ankle to reduce motion of the painful joint. Elevation and icing to the ankle is helpful to reduce swelling. Non-steroidal anti-inflammatory medications are usually prescribed to aid in pain control and swelling. Crutches may be necessary to assist with ambulation.

Once the acute inflammatory phase is over, physical therapy is prescribed. Gentle range of motion exercises are begun as tolerated. This is followed by strengthening exercises to the muscles of the lower leg. Graduated, sport-specific exercises are then initiated with the goal to return the athlete to sports when he or she is able to run, jump, cut, and pivot without pain. An ankle brace or taping of the ankle may help reduce the risk for recurrent injury once the athlete returns to sports.

Surgery is rarely necessary for high ankle sprains and is indicated only if there is significant injury to the ligaments around the ankle resulting visible separation of the tibia and fibula bones. In this situation, an orthopedic surgeon will place one or two screws across the two bones to restore their normal anatomic relationship.

When Can Athletes Return to Sports Following a High Ankle Sprain?

Despite the fact that most athletes who experience a low ankle sprain can return to sports within one to three weeks following the injury, those players who sustain a high ankle sprain are often out of sports for four to six weeks depending upon the injury severity. Sports that involve cutting and pivoting, such as football, are especially difficult to play in the setting of a high ankle sprain. The player’s position may also dictate the length of recuperation as running backs or linebackers who have to quickly change direction are often the most disabled with this injury. For those athletes who require surgery, sports activity can usually be resumed in approximately four months. Therefore, surgery for this injury typically results in an inability to return the same season. Once an athlete sustains an ankle sprain, he or she, unfortunately, is more prone to future injuries.